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A three year study, started in Spring 1985, is intended toreveal the intellectual, ethical and interpersonal development of medical students at a large Canadian university during their undergraduate medical education and the extent of congruence between these changes and the developmental changes in students anticipated by the Faculty of Medicine. It is intended also that the authors will examine the extent to which characteristics of the medical school learning environment (a) are supportive of desired and anticipated student developmental changes, (b) are related to observed student changes and (c) are consistent with the Faculty mission and the premises and objectives of the undergraduate medical curriculum. This report describes one phase of the larger study, specifically, the perceptions of the learning environment obtained from 51 of 57 faculty who serve as Undergraduate Course Supervisors. Analysis and interpretation of these perceptions with reference to the goals and objectives of the larger study are also provided. [ABSTRACT FROM PUBLISHER]

An innovative program, introduced into a tradition-based undergraduate medical school curriculum, was evaluated using an ethnographic approach for data collection and analysis. The objective of theevaluation study was to provide data in support of rational decision making with respect to the future of the innovation. This article describes the methodology andprocesses used to evaluate the innovation and assesses the strengths and weaknesses of the evaluation. [ABSTRACT FROM PUBLISHER]

Background: Research into adverse events in hospitalized patients suggests that a significant number are preventable. The purpose of this randomized, controlled study was to determine if simulation-based debriefing improved performance of practicing anaesthetists managing high-fidelity simulation scenarios., Methods: The anaesthetists were randomly allocated to Group A: simulation debriefing; Group B: home study; and Group C: no intervention and secondary randomization to one of two scenarios. Six to nine months later, subjects returned to manage the alternate scenario. Facilitators blinded to study group allocation completed the performance checklists (dichotomously scored checklist, DSC) and Global Rating Scale of Performance (GRS). Two non-expert raters were trained, and assessed all videotaped performances., Results: Interim analysis indicated no difference between Groups B and C which were merged into one group. Seventy-four subjects were recruited, with 58 complete data sets available. There was no significant effect of group on pre-test scores. A significant improvement was seen between pre- and post-tests on the DSC in debriefed subjects (pre-test 66.8%, post-test 70.3%; F(1,57)=4.18, P=0.046). Both groups showed significant improvement in the GRS over time (F(1,57)=5.94, P=0.018), but no significant difference between the groups., Conclusions: We found a modest improvement in performance on a DSC in the debriefed group and overall improvement in both control and debriefed groups using a GRS. Whether this improvement translates into clinical practice has yet to be determined.

High-fidelity patient simulation allows students to apply their theoretical knowledge of pharmacology and physiology to practice. The purpose of this study was to determine if experiential education using high-fidelity simulation improves undergraduate performance scores on simulation-based and written examinations. After receiving research ethics board approval, students completed a consent form and then answered a ten question multiple-choice quiz to identify their knowledge regarding the management of cardiac arrhythmias. Four simulation scenarios were presented and students worked through each scenario as a team. Faculty facilitated the sessions and feedback was given using students' videotaped performances as a template for discussion. Performance evaluation scores using predetermined checklists and global rating scales were completed. Students then reviewed the American Heart Association guidelines for the management of unstable cardiac arrhythmias. The afternoon session involved repetition of the four case scenarios with the same teams involved but different team leaders. Students then repeated the quiz they received in the morning. Descriptive statistics, paired t-test and repeated measures analysis of variance (ANOVA) were used to analyse results. Two hundred and ninety-nine students completed the study. There was a statistically significant improvement in performance on the pharmacology written test. Simulation team performance also statistically improved and a good correlation between checklist and global rating scores were demonstrated in all but one scenario. Student evaluation of the experience was extremely positive. High-fidelity simulation can be used to allow students to apply theoretical knowledge to practice in a safe and realistic environment. Results of this study indicate that simulation is a valuable learning experience and bridges the gap between theory and practice. Simulation technology has the potential to provide an enriching venue to examine the role of communication and dynamics of novice learners in team environments.

Purpose of Review: We provide an overview of the developments in medical education and assessment using high-fidelity simulation. Both descriptive and research papers recently published in the English language are included in this review., Recent Findings: The majority of articles reviewed are descriptive in nature, outlining the use of simulation for various educational purposes in undergraduate, postgraduate and continuing medical education. Some articles focus on the use of simulation for the acquisition of technical skills in different surgical disciplines using part-task simulation. Other disciplines such as emergency medicine, critical care, paediatrics and nursing have also contributed to the literature in this area. Very little research in the area of simulation is evident in the literature addressing the actual value or the reliability and validity of high-fidelity simulation as an evaluation tool during this time period. A strong interest in decreasing human error and the improvement in patient safety may indicate the future direction of high-fidelity simulation., Summary: Simulation is receiving increasing support as an educational tool and in its use for evaluation purposes. Research into this area is still somewhat limited. As the research impetus increases in the future, we may see simulation as a major focus in all disciplines with respect to its use in the improvement of patient safety. Team training, including both personality and attitudinal issues similar to those performed in other high hazard industries, may become increasingly evident in the literature in the coming decade.

Purpose: In response to the Royal College of Physicians and Surgeons of Canada Maintenance of Certification Program (MainCert), a research project was designed to determine the modality by which practicing anesthesiologists in Ontario would like to undertake their continuing education courses. We wished to explore whether interest in electronic delivery correlates with gender, age, location of practice, appointment to teaching hospitals or number of years in practice., Methods: Following University of Toronto Ethics approval, a survey questionnaire was sent to 875 anesthesiologists practicing in Ontario. Included with the questionnaire was an offer of a free module to be delivered by e-mail, regular mail or fax that could, upon completion, generate MainCert credits., Results: Of the 875 questionnaires mailed, 413 (47%) were returned. A total of 404 responses, 113 from female (30%) and 291 from male (70%) anesthesiologists, were entered in the database. Three hundred and thirty three respondents requested the module and of these 51% preferred delivery by regular mail, 40% by e-mail and 3% by fax. Chi squared tests showed no significant differences between gender, among age groups, location of practice nor affiliation with university/teaching hospitals. When asked to rate their level of comfort with the Internet on a ten-point scale (1 = low, 10 = high), 59% of respondents indicated a level of 8 or higher. Of those who preferred regular mail, 40% indicated that they were also comfortable with electronic communication., Conclusion: It was concluded that both e-mail and regular mail options should be offered to facilitate continuing medical education.

Unlabelled: In this study we sought to identify educational gaps in medical students' knowledge using human patient simulation. The Undergraduate Committee developed 10 scenarios based on anesthesia curriculum objectives. Checklists were designed by asking 15 faculty members involved in undergraduate education to propose expected performance items at a level appropriate for medical students. These items consisted of essential performance items as well as critical management omissions. Checklists were used to score students' videotaped performances. Checklist items common to more than one scenario were grouped for data analysis and identification of gaps in achievement of educational objectives. Eighteen groupings of expected performance criteria and 8 groupings of critical management omissions were established. Performance data of 165 students were analyzed. Common management omissions were lack of adequate airway management, failure to check blood pressure, and failure to stop the anesthetic. Students reliably performed defibrillation, notation of vital signs, auscultation of lung fields, and administration of IV fluids. The most common critical omissions were failing to a). call for help, b). take a history/do physical examination, and c). prepare airway equipment. Management and critical omissions noted during performance assessments provide information regarding students' educational needs, enabling faculty to focus attention on demonstrated areas of weakness., Implications: This study involved the use of high-fidelity patient simulation that offers standardized clinical experiences that can detect gaps in medical students' knowledge base and clinical performance. This information can be used by faculty to focus their teaching efforts to ensure competency in important educational areas.

Purpose: To gather information regarding the global use of simulation technology in education, evaluation and research in anesthesia., Methods: The WorldWide Web was searched and located sites with simulation centres (n = 158) were mailed a 67-item questionnaire requesting information regarding demographics, personnel, education use and research involvement. Comments were solicited. Medical school data only are reported in this article., Results: Two web sites were used to generate the list of simulation centres. Sixty responses were received (38%), with 41 emanating from medical schools. Seventy-seven percent of centres were involved in undergraduate education and 85% in postgraduate education. Few centres were involved in evaluation and/or competency assessments. Sixty-one percent of centres indicated ongoing research with a further 25% interested in international collaboration. University or university departmental-based funding largely supported simulation technology used in medical schools. The lack of financial and human resources was the single most common problem identified by respondents., Conclusions: From the survey responses received, opportunities for the simulator to be used for the assessment of performance appear to be under-utilized. This may be due to the lack of research in this area, lack of standardized, valid and reliable tests and the fact that most centres have only recently acquired this technology. Further research supporting the use of the simulator in education and evaluation is required.

The anesthesia computer-controlled patient simulator offers a valuable experiential learning experience for undergraduate medical students. The purpose of this study was to gather students' opinions of the simulator learning experiences and to study and analyze their comments regarding the nature of the learning. All fourth-year medical students were invited to participate in a simulator session during their anesthesia rotation. A satisfaction survey was administered and the qualitative data were analyzed. A total of 145 students completed the questionnaire (100% return rate). Most students (88%) reported the session to be a positive learning experience that provided opportunities for applying their knowledge in a realistic environment. Some students indicated a lack of comfort in the environment but this did not appear to inhibit performance. Student comments highlighted the value of the learning experience and provided insights into the nature of the learning. The computer-controlled patient simulator offers new and challenging opportunities for medical students to apply their knowledge and practice working through an Anesthesia case without endangering patient safety.

Purpose: To determine the correlation between global ratings and criterion-based checklist scores, and inter-rater reliability of global ratings and criterion-based checklist scores, in a performance assessment using an anesthesia simulator., Method: All final-year medical students at the University of Toronto were invited to work through a 15-minute faculty-facilitated scenario using an anesthesia simulator. Students' performances were videotaped and analyzed by two faculty using a 25-point criterion-based checklist and a five-point global rating of competency (1 = clear failure, 5 = superior performance). Correlations between global ratings and checklist scores, as well as specific performance competencies (knowledge, technical skills, and judgment), were determined. Checklist and global scores were converted to percentages; means of the two marks were compared. Mean reliability of a single rater for both checklist and global ratings was determined., Results: The correlation between checklist and global ratings was.74. Mean ratings of both checklist and global scores were low (58.67, SD = 14.96, and 57.08, SD = 24.27, respectively); these differences were not statistically significant. For a single rater, the mean reliability score across rater pairs for checklist scores was.77 (range.58-.93). Mean reliability score across rater pairs for global ratings was.62 (.40-.77). Global ratings correlated more highly with technical skills and judgment (r =.51 and r =.53, respectively) than with knowledge. (r =.24), Conclusion: Inter-rater reliability was higher for checklist scores than for global ratings; however, global ratings demonstrated acceptable inter-rater reliability and may be useful for competency assessment in performance assessments using simulators.

Purpose: To examine the validity and reliability of performance assessment of undergraduate students using the anesthesia simulator as an evaluation tool., Methods: After ethics approval and informed consent, 135 final year medical students and 5 elective students participated in a videotaped simulator scenario with a Link-Med Patient Simulator (CAE-Link Corporation). Scenarios were based on published educational objectives of the undergraduate curriculum in anesthesia at the University of Toronto. During the simulator sessions, faculty followed a script guiding student interaction with the mannequin. Two faculty independently viewed and evaluated each videotaped performance with a 25-point criterion-based checklist. Means and standard deviations of simulator-based marks were determined and compared with clinical and written evaluations received during the rotation. Internal consistency of the evaluation protocol was determined using inter-item and item-total correlations and correlations of specific simulator items to existing methods of evaluation., Results: Mean reliability estimates for single and average paired assessments were 0.77 and 0.86 respectively. Means of simulator scores were low and there was minimal correlation between the checklist and clinical marks (r = 0.13), checklist and written marks (r = 0.19) and clinical and written marks (r = 0.23). Inter-item and item-total correlations varied widely and correlation between simulator items and existing evaluation tools was low., Conclusions: Simulator checklist scoring demonstrated acceptable reliability. Low correlation between different methods of evaluation may reflect reliability problems with the written and clinical marks, or that different aspects are being tested. The performance assessment demonstrated low internal consistency and further work is required.

Purpose: The Department of Anaesthesia undertook a qualitative study to a) reveal the characteristics of teachers who had been identified as "good," and b) explore the levels of epistemological development (defined as conceptualization of knowledge) that are evidenced. Changes in medical education curricula have focused attention on the ways in which medical teaching staff conceptualize the learning/teaching interactions and their ability to alter or modify their teaching styles. Teachers are often assessed or informally recognized as "good teachers," but there are few indicators to guide what is meant by the label in anaesthesia., Methods: Teachers who had consistently received overall ratings of 4+ on a 5 point rating scale over a five year period were selected to be interviewed. Data were analyzed a) noting key teaching characteristics and patterns of teaching and b) within the framework of adult development theories., Results: Good teachers in Anaesthesia all identified six characteristics necessary for good teaching. They were characterised by their "inquiry" approach to teaching, their complexity of thought and their functioning at higher relativistic/Commitment levels of epistemological development., Conclusion: Teaching in anaesthesia is depicted by the need to address multiple aspects of thinking and action. Good teachers are aware of these aspects and include techniques that offer residents opportunities to develop their thinking skills to deal with medical complexities as well as guiding learners to increase their knowledge. The interviewed teachers' revealed approaches to teaching and learning that indicated their own personal cognitive complexity and levels of development.

The clinical clerkship in Canadian Medical Schools is intended to provide senior medical students with opportunities to gain practical knowledge of clinical medicine, develop technical skills, learn to use judgement and experience first-hand clinical decision making. Assessment of rotations in internal medicine were undertaken in order to understand more fully the nature of medical clerkship experiences. We found that medical clerks in our programme were exposed to a high proportion of undifferentiated problems and an adequate case mix. They performed a wide range of technical procedures. There were, however, certain gaps in the clerks' experiences both in the specialty areas, and in therapeutic and technical procedures. Recognition of these gaps in the clerkship experiences suggest that further deliberation of goals and objectives is required and issues of achievement of competencies need to be addressed.

To detect any change in medical students' attitudes toward medical ethics, students from the same class were given a questionnaire on their first day of medical school and again near the end of their fourth year of study. The results showed a strong shift away from the students' initial expectations that they would rely on specialists or scholarly sources in the future; the need for a medical ethics course in the curriculum, while still felt, was less important to them by the fourth year. The reasons for these changes were not apparent, for the students' levels of knowledge and perceptions of the role of ethics in medicine in the first and fourth years did not differ. It is recommended that medical school faculty actively reinforce the initially positive attitudes of students during clinical supervision.